HomeMy WebLinkAbout4449DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www. s ca n y o u rd o cs : co m
631- 589 -8100
84.14 -1 -22
BOX 34
;Mimi 0�m
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go 610.
1 T � N
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PUTNA COUNTY D
M EPARTMENT OF;HEALTH: < ';
Rev 61 vivlsion of Envlronnegtal Health Services, t arme14N Y. 10512 ~`
v �� Engineer Mast Provides
°"' • _ ZIr1T1_TC;ATE.®:0 • ,. N �Rf3C1IGN`iGUMi'1IA3VGE FOR SEiI'AGE iSPO$AL SYSi 1bY
i
lllag
. Town or .V
.
Located at . d �'. ��l� Tat: MaP�Block Z Lot
Owner /applicant Name / n jI? � 'FO.er�Y Subdivision Name Subdv. Lot N
Melling Address Date Permit Issued
Separate Sew- erage System .built bye .. Address j dS /sue h rl �gN
Con`sieting of f � Gallon-Se tic Tank and
Water. Supply.... /Public Supply From Address
or, r Private Supply Drilled by ' / rn J-00_54`7 Address .2 P—G gw • Pro,
•
Bapding.Type v • ' Has Erosion Control Been CompletedR
Number of Bedrooms `� HM Garbage deluder Been Installed?
Other Requirements
—
I certify that the system(s) as'listed.servinq.the above premises were constructed essential n ^th of.the completed work ( copies
of which are:atiached), and in acoordance'with.the standards, 'rules* and 'regulations, in ac ' c ^ U e_. and the permit.issued by the
Putnam County. De rtment Of Health.
4
Date Cootified by
P.E. RA
Address d/ ' r nse No.Z if " 7s
Syr °,
Any person occupying premises served by "tn bove syitem(s) shail'promptiy take such action s " be t sac, ay►i correction of any unsanitary
conditions resulting from such usage .Ap rovsi oi`the. separate sewer system,stulPDeco`_ eau ntl�tw,ol as ' n ubi'. sanitary sewer becomes
available and the approval.of the piivate vyster.supply,shall.beco,me nLi d Vol when a" a_ ' POP allable. . Such approvals are
subiect to m dif o o Change when, in the judgment of the _Co issioneY ' M a PI or change lt, r .
Date ay Tit re
M
^%T 'nil nnnm
Wn.Lj� UUrLrjjr11LV" "LILV".L
DEPARTMENT OF HEALTH
4*
nv r.Q=en rv-ices:..,.
!;a _Hea�lth se,
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
7
WELL LOCATION
511flifiEr)OUR S. ,4WNIVIL IY TAX GRIO NUMBER:
( rze
WELL OWNER
OOR.
e� i )�LPRIVATE
1� 0, 0 PUBLIC rn -2 3 9�� ESSe - I -
JkRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST/OBSEAVATION 0 OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL - ❑ STAND-GY ❑
USE OF WELL
1 - primary
2 - secondary
AMOUNT OF USE
pm. /N0. PEOPLE SERVED --�/ EST. OF DAILY E
.YIELD SOUGHT USAGE gal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TESTIOBSCERVATIO'N
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH )0 I, TtSTATIC
WATER LEVEL eft.
1 DATE MEASURED Ike '7
DRILLING
EQUIPMENT
ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT 0 CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK 0 OTHER
CASING
TOTAL LENGTH ft.
MATERIALS: 19 STEEL ❑ PLASTIC 0 OTHER
LEINGTH.BELOW GRADE 2-ft.
JOINTS: OWELDED aTHREADED CIOTHER
DETAILS
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE .OTHER
WEIGHT PER FOOT /S' -Ib./ft.
DRIVE SHOE 59-4ES ONO
I LINER: O YES ZNO
SCREEN
DIAMETER (in)
5L0T SIZE
LENGTH (ft)
DEPTH TO SCREEN (11)
DEVELOPED?
FIRST -
Ir
Q-
HOURS
SECOND
GRAVEL PACK
11 YES
0 NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
LTOOE
OEM It.
BOTTOM
OEM
WELL YIELD TEST If detailed pumping
METHOD: ❑ PUMPED 1 tests were done is in-
COMP . RESSED AIR formation attached?
0 BAILED 0 YES 0 NO
0 OTHER
'If more detailed formation descriptions or sieve analyses
WELL LOG are iivdilable. please attach.
DEPTH FROM
SURFACE
I
water
Bear-
ing
Well
Oi3-
meter
In
FORMATION DESCRIPTION
poE
it.
It.
WELL DEPTH
It.
DURATION
hr. min.
DRAM
'It.
YIELD
9pm.
Surface u
S r1a
-
S-
WATER ❑ CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK: TYPE
CAPACITY YD GAL. Y 6
PUMP IMF RMATIQN
Typr CAPACITY
MAK DEPTH 34Ft) f
MODEL X61 VOLTAGE13-0— HP
WELL D%LER NAME 0 T
7
AODR043
�zf�
PUTNAM COUN'T'Y DEPARTMENT OF HEALTH
_ Dr . � , S T Cal v x ,
A .HEALTH ,. -SEA UTC!E
Owner
.J % �
� r/ d4114Q L --C
Location - Street
(it, vtlatC4 '
Municipality.
,,&u cr
Building Type
1/9 _.0 Z?..,
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
workmanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards,. rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate._ for a. rerio.d,-,of _two .years imnediately following the date of approval of the
"Certificate of *Construction Compliance "afar- the - sec�age dzGgo 1: sy t u� .:r�r_ any:_
repairs made by we to such system, except where the failure to operate properly is
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant Qf the building utilizing
the system. ,I j
Dated this _'day of 19� Signature
' Title
Genes 1 Contract r)(Owner) - Signature
Corporation Name (i Corp.
1,3 u-AuQu" LQ6
Address i/'
rev. 9/85
mk
9v /D iGkC
Corporation Name (if Corp.)
Address 1,09
Yorktown Medical Laboratory, Inc.. LAB 1 32.011942
321 Kear Street Date Taken: Time:
Yorktown Heights, N. Y. 10598 -4 -VY
Date.Rcld: a .,-.Time:..
7,
R ip�
e -6 it
4� 7:
Director: Albert H. Padovani M. T. (ASCP) Collected By:
Referred By:
C/' Sample Location:
Phone #
Phone # Sample Type:
Repeat Test?. I(check one)
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
tZ'Standard Plate
(Agar Plate
Count (CFU/1.OmL)
8 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
Total Coliform (CFU/100mL)
Fecal Coliform (CFU/lOOmL)
Fecal Streptococcus (CFU/lOOmL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
Total Coliform: MPN Index (per lOOmL.)
MPN-In e r'- ffl mf I—
OTHER ANALYSES,
REMARKS (For Laboratory Use)
0
v-"'Potable
Non-potable
STP INF
STP EFF
Other:
Sample Status:
(check each)
Outgoing
— Na2S203
Incoming
✓L E 4°C
GT 40C
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tion of Source
TNTC= Too numerous To Count
CON = Confluent (=TNTC)
LE = Less Than or Equal to
GT = Greater Than.
N/A = Not Applicable
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) ( WASN'T) (NIA) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T� YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
For Lab Use Only:
H/C to
PZ
Albert H. Padovani, M.T. (ASCP), Director
IT.
ITT.
V.
Vi.
P -PPEND -X C a,
• i a F SITE INSPECTION Date % V
ns tai
Tv-
-4CATN T_O I �� C4ulER �;
-,'ir Ir
S -.E DISPOSAL ARFA
a_ SDS area lccated as per approved plans
b. Fill secticn - Date of.placen--nt
2:1 barrier . LGTH VY= AVG_DPTE
c_ Nat -,,rat soil not stripped
d_ Stone, brush, etc-, gre=_ter than 15' fran SDS -are=._
e. 100 ft_ fran water ccur_ - •etlands. I
I
SLnu.SYSTEM DISPOSAL SYSTEM
a_ Septic tank size 1,000 1,250
b. Seotic tads insi lea _vel
c. 10' mini =n frcm fcurdation (
I
d_ No 90° cl =. =scut within-lo ft. of 45° Lend
e. DIS •• LUTT_GIv EQX (
1. P -1..1. outlets at =-clue ele�r=ti cn -water test
I
2. Protected belcw frost
I I
,I
3. Minimum 2 .f t. ericinal soil b t-we =n box and tran- ches
I
I
f. JUNCTION BOX -- rccrl set
I
9-
1_ LancLh rem- e - Le_nc�Lll ips-a le:d,�j -C I
-
2. Dlst?S!ce to we s'ared ft_
Imo- -I
I
3. Irista11-e-d- acccrd; nq to plan
I
4 Distance centar to center 6L
I
5. Sloce of tra-ca accent_ble 1/16 - 1%32 " /icct_
6. 10 feel. fran prcre_rty line - 20 feet - foundaticns
I
I
7. Depth of trer_cZ < 30 inches frcm surface
8. Roan a:Llcwed for e_nsion, 50%
9. Size of gravell 3/4 - 11" diz_*neter
i
10. Depth of gravel in trench 12" u i rC,-ra ,
I
I
...
h. PLLD OR DOSE SYSZMS . _._.. _... ... ..-
1. Size of pum
,....�:..:. _ _ ...,... "�.. _ .
2. Overflc,q t---Pk
I
3. Alann, visoG? /a�^io
I
I I
4. Pmo easily acce_ -sible maphole to grade
5, First box baffles
6. cwcle witne_sei by Ee alth Dera.r- tme_nt
estimated flew per evcle
I ;'
EGUSE
a_ House lc<wted pe_r apprcved3 plans.-
I
l
b. Nmil- r of bedroczvs
wrr,r.
a. well lo=---teed as pEr approved plans
t'
C-1-1 Jm
b. Distance fran SDS area ire—asured InET ft.
I K
I I
c. Casing 18" above trade_
I
d. Surface d_rair_ce around well acceptable.
i
GVERALL WORK%PSP?P
a_ Bcxes prcc.E—:,-ly grcuted
f
b. A1.1 piEes partiall1v backfilled
I
c. All pioes flush with inside. of box
d. Bacic-Zill material contains stones < 4" in dizumater
I
e_ Obtain drain installed according to plan
f. Ourtain drain cut=all protected. & dir_to exist_wate_rccurs
'
9. Fcotinq drai-is discharce aw--y trcm SDS . area
h_ Sur-face water rot --ticn adequate
I
i_ E:.osion cintro provided on slopes q- re -ter 15 %_
I
n z .w4 a Y }a fi r MrEr t u.
V.
2
PUTN 'M COUNTY, DEPARTMENT OF HEALTH' ENGINEER TO PROVIDE .PERMIT #
CERTIFICATE OF COMPLIANCE.
ONiston of Enwronmenial , Healih . Serwces Carmel N Y 10512
PERMIT "I
—�,
CONS UCTIO „ ;x •4 w J
N PERMIT 'FOR .,SEW,AGE„ DISPOSAL SYSTEM
..Town-,o r Village
° r�L'oce'e6r ar �i'"`" "��'� � __ _. .,.. r `< : � ux •�7lap /�'y�aco at#Toe<r �F'`? r-�y- Lot '` "�_.i?y,"�s�.'.-� .. - ..
subd. Lot•# - Renewal Revision
Subdivision � ,.� ❑ :. .
�' -'� Date Of Previous Approval
owner /Address 54 4 >� :! ✓
uiltling Type`' Lot Area '�i Fi
t3 11'section Only ❑'
Number of Bedrooms -, Design Flow G /P /t) : - -.4�Q. H. D. Notification Required
Separate.5ewera a System to .consist of O: �> �.. r< • . j //
g J Q Gal Septic Tank and•
To be constructed.' by " Address
Water Supply: ublic Supply From
i
Private Supply' to be drilled by _
Address s `'
Other Requirements ~^
f.cepresent'th`at -I am wholly and completely .responsible for the tles�gn and loc5tion of the proposa& i
above described will be constructed $`i shown_on the approved amendment there ao and in.accordance w
County, Department of Health, and thai , omcompletion- thereof a Certificate -ot 'COnstrucUon C 71
be submitted to.the Department and a written guarantee will be furnished the owner, his
place in -good, operating-. condition any part-of said sewage disposal' system during the peii�
ante of- the approval of 'the Certit.iwte of. Construction Compliance of the original system�or
Will be "located as•silown on the approved planand,that, said well will be 1, nstalled in accordan4.4vii
County Department of Health'.
Date
Address lr /��
n4
APPROVED FOR CONSTRUCTION: Th approval expires one year from t e:'date issued u s cd
revocable for, cause or may be amends r'modified when considered rigcessar "y by tfie Commfssior'e
requires a new permit. , Approved for disposal of domestic QlAitary, sewaga, an or, rivate .vvatel�e
Date _2 C) —i Jb gy &AYWU , <
-- .Rev.. 6/85
m
ry -to "the- Commissioner of Health will
_yAhe'.builder ttiat said builder will
Vr ,Sim "tely following the date of the issu-
iei ° t gthe- drilled well. described above
i Isi a s a regu actions .of'. the Putnam
P.E. R.A.
`icense Nor 5�
Loaf fiy�' iIdmg has been undertaken and is
amA jfS' change or `alteration of construction
Title rte=
Subdivision t / /) subgd.. rots 0 �/
Owner /Address__ l 1 e �L/ /' rj �Y'C� � y/ lip' 40,-A04& l C'.-arArff 'J/
Building .Types ° Lot Area
Number of Bedrooms -3—Design Flow G /P /D
Separate Sewerage System to consist of j '0 aG' 'Gal. Septic Tank
To be constructed by
Water Supply: lic Supply From
Private Supply to be
drilled by
Address ,qG �']
Other Requirements /� .l�rrr;rJ
Renewal _ ❑ Revision
Date-Of Previous Approval
Fill Section Only, ❑
P.C. N. D.Q.Notification Required
and 2' vi ;,,Ie
Address
1 represent that I am wholly and completely responsible for the design and location of the proposed system(s). 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regulations o e Putnam
County Department of Health, and that on completion thereof a "Certificate of Construction Complianc%',%Vi ory to the Commissioner of Health will
be submitted to the Department, and a written guarantee will be furnished the owner, his successor "Qirbpr hy' the builder, that said builder will
place in good operating condition any part of said sewage disposal system during the period of.t4ilo40i,ggr�da ly following thedate of the issu-
ance of the approval of the Certificate of Construction Compliance of the original system or a.ny re , o;gj a drilled well described above
will be located as shown on the approved plan and that said well will be Installed in accordance wit.. the,°>landards,�� sa d ulaeons f the Putnam
County Department of Health. p�m
Date
Address J /.d�
No.
P.E. R.A.
APPROVED FOR CONSTRUCTION: Th' a n °
pproval expires one year from he date issued un s; construction of the has been undertaken and is
revocable for, cause or may be amended ,6r modified when considered necessary by the Com issioinei•. of -.,l ealt i ';.`'Arf' ooh or alteration of construction
requires a ne permit. Approved for disposal of domestic nita y sewage and /or p to ater. supply only.• °� v {yo
— o
Data By S title
Rev. 9 -81
F m .,fit • -y
r PST NAM COUNTY DEPARTMENT OF HEALTH Permit a
j`
Division of Environmental Health Services, Carmel,
Y.. 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
.N.
zl',4 , I
Ile,
Located at
a�`Y i� .Js� `ij C Tax Map_I / elock Lot' 1�t cy.. Z-� ' -
Subdivision t / /) subgd.. rots 0 �/
Owner /Address__ l 1 e �L/ /' rj �Y'C� � y/ lip' 40,-A04& l C'.-arArff 'J/
Building .Types ° Lot Area
Number of Bedrooms -3—Design Flow G /P /D
Separate Sewerage System to consist of j '0 aG' 'Gal. Septic Tank
To be constructed by
Water Supply: lic Supply From
Private Supply to be
drilled by
Address ,qG �']
Other Requirements /� .l�rrr;rJ
Renewal _ ❑ Revision
Date-Of Previous Approval
Fill Section Only, ❑
P.C. N. D.Q.Notification Required
and 2' vi ;,,Ie
Address
1 represent that I am wholly and completely responsible for the design and location of the proposed system(s). 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regulations o e Putnam
County Department of Health, and that on completion thereof a "Certificate of Construction Complianc%',%Vi ory to the Commissioner of Health will
be submitted to the Department, and a written guarantee will be furnished the owner, his successor "Qirbpr hy' the builder, that said builder will
place in good operating condition any part of said sewage disposal system during the period of.t4ilo40i,ggr�da ly following thedate of the issu-
ance of the approval of the Certificate of Construction Compliance of the original system or a.ny re , o;gj a drilled well described above
will be located as shown on the approved plan and that said well will be Installed in accordance wit.. the,°>landards,�� sa d ulaeons f the Putnam
County Department of Health. p�m
Date
Address J /.d�
No.
P.E. R.A.
APPROVED FOR CONSTRUCTION: Th' a n °
pproval expires one year from he date issued un s; construction of the has been undertaken and is
revocable for, cause or may be amended ,6r modified when considered necessary by the Com issioinei•. of -.,l ealt i ';.`'Arf' ooh or alteration of construction
requires a ne permit. Approved for disposal of domestic nita y sewage and /or p to ater. supply only.• °� v {yo
— o
Data By S title
Rev. 9 -81
r
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property of .�i C% An dew ��� r -�' •
Located at ry,g 4-e�e'rj
(T) ��J`i >d7 v�t Section / Ot Block : Lot 2-0, 2-
Subdivision of
Subdv. Lot # Filed Map # Date -*-
Gentlemen:
This letter is to authorize.�`'�1 %, ✓`
a duly licensed professional engineer -- . -T— or registered architect
(Indicae
to apply for a Construction Permit for a. separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system-or.-systems. in .conformity, with, the., prqx.is ions .o£.. Article 145 --or. .. _
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
P.E., R-. ., # 2 y
Address
7
Very truly yours,
Signed
0 er of PrcWe " tly
b
Y Address
Town
Telephone
7e Lj2 y Y
Telephone
JOSEPH F. SULLIVAN, P.E.
2972 F(ERNCRCBT DRIVE
"Ma- `YORKT6WN HE H
(914) 962-4248
Narch 80 1986
Putnam County Heal . th Department
bout® 52
Putnam County.-Qffie e Building
Oarmel, N.Y. 10512
Gentlemen,
From asite inspection of Sieglinde Geyer!a lo't'on
Wilma Lane in the town' of Putnam Valley (sheet 119 Block 2
Lot 20.2 there have been no changeii,to adversely a . ffe . at
the proposed saw . age'disposal system or the lodation of
the proposed well., This lot had approval for the proposed
sewage disposal system on Permit No PV 6-85o
Very truly yours
001
Joseph F, Sullivan P.,E*
'00
40 i��
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N .''Y'. Y0512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner . ,J � e4- -e el" Address %j4ior^o✓le,
Located at (Street )-C-ne- Sec. Jl 9 Block Lot
6dica.Ee nearest cross s ree
Municipality, �cf , i r✓� 4 c le /ry Watershed
SOIL PERCOLATION TEST DATA REQ IRED TO BE SUBMITTED WITH APPLICATIONS-
Hole- e- :..-
Number CLOCK TIME PERCOLATION PERCOLATION
RaT .. .. ...... apse 'Depth to Water . Water , Ve
No. Time From Ground Surface in Inches Soil Rate
"Start-'Stop Min. Start' Stop Drop-in Min. /in drop
Inches Inches Inches
Zj
3
5 .
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. A11 data to be submitted
for review.
2) Depth measurements to be made from top of hole.
2 �--3U
57'x'
a Q_T"/.��i
Zj
3
5 .
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. A11 data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
�: _
DEPTH HOLE NO. - HOLE NO. «.HOLE NO.
G.L. r� r
611
12"
18" -
24"
3011..
8411
INDICATE LE�TEL AT -WHICH GROUND WATER IS ENCOUNTERED
INDICATE :LE�TS�� ..-TO LEVEL RISES AFTER�tEING�ENCOUNT
_ ..
TESTS', MADE BY w . ..-" �.v. j `', - Date
DESIGN
Soil Rate Used Mir4/1 "Drop: S.D. Usable Area Provided e c ov r%i ,�-
No. of Bedrooms Septic Tank Capacity 40 0 Gals.' Type Lj
Absorption Area -Proms By, ay L.F.x24 " width trenc .
<r
G
vy0ther, , , , ,cam
Address ? `�)�� j=Gr GrG `�" or,
it
17r (jWA 12S
THIS SPAd FOR USE BY HEALTH DEPART
Soil Rate Approved Sq. Ft /Gal.
bignature
si t:
.eu�ae -. �.
O
ONLY:
nil
Checked
by
�Date
PUTNAM I,i M:X L UJPUClr'1M1 Ur Hh:AUNki - DIVISION OF ENVIROMMAL HEALTH SERVICES
INDIVIDUAL LATER SUPPLY /SUBSURFACE SEWhGE DISPOSAL SYSTEMS
FIELD INSPECTION REPORT
j DATE: > ' 2 7`&
INSP. BY:
INITIAL SITE INSPECTION a YES NO COMMENTS
Property lines or corners found ................... GUSuw�, )'
Can estimate house location .....:................. .
Will driveway need cut.
.......... .....
Must trees be removed - note these ........:.......
Deep hole representative of entire SDS area.......
Additional deep holes needed.......... .
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc... �-
Adjacent wells/ septics .. ...........................
D.H. 1 Lot
Depth to G.W.
Depth to rock
Soil Descriotic
0 ft.
3 ft..
6 ft.
9 ft.���
12 ft.
D.H. 2 Lot
Depth to G.W.
Depth to rock
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
boll llescr
—
J
D.H. - Deep Hole
G.W.- Groundwater
D.H. 3 Lot
Depth to G.W.
Depth to rock
0 ft.
3 ft.
6 ft.
9 'ft.
12 ft.
Soil
--
DAMP:
FINAL SITE INSPECTION INSP.BY:
YES
NO
COMMENTS
House SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Rocco allowed for expansion trenches ..............
Over 100 ft. from swamp, watercourse .............
Natural soil not stripped or SDS area
unnecessarly graded ............................
10 ft. maintained fran property line and
20 ft. fran house ..............................
Distance well to SSDS (ft.) ......................
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ....:...........
15 ft. of peripheral soil horizontally
fran trench ..... ...............................
Boxes properly set ...............................
:ould surface runoff fran driveway, roads,
, ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
FINAL GRADNG OF SITE AOC PTABLE.. ... ...
rev /9/85
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